Air Date: Week of January 22, 1999

Iodine deficiencies haven't been a problem for Americans in decades. But in Pakistan, this age-old curse is returning with a vengeance, causing problems including mental retardation. Deforestation and flooding wash the iodine out of the soil and don't allow it to work up through the food chain. Government warnings aren't reaching the right people, and there are rumors that it is actually a plot to cut population growth.

Transcript

CURWOOD: It's to NPR's Living on Earth. I'm Steve Curwood. The government of Pakistan is appealing to the international community for help in tackling an acute health problem: a lack of iodine in its population's diet. In most of the world iodine occurs naturally in the soil and then works its way into the food chain. But because of massive deforestation in Pakistan, the vital nutrient is literally being washed away as the soil erodes. As a result, millions of Pakistanis are at risk of iodine deficiency disorders, including goiter, and mental disabilities, along with stillbirths and high rates of infant mortality. Richard Galpin has our story.

GALPIN: A shortage of naturally occurring iodine in the soil has been a problem in many parts of the world, in both developing and developed countries. While in many of these its been tackled successfully, in Pakistan this has not been the case. Steve Omemato represents the United Nations Children's Fund, UNICEF, in Pakistan.

OMEMATO: It's a very serious problem. Our estimates range from 40% upward of the population being vulnerable to iodine deficiency. And as you know, iodine deficiency is the largest contributor to mental retardation in the world, and this of course applies to Pakistan as well. So, we are talking, literally, about millions of children who are at risk of iodine deficiency, mental retardation, extreme cases of cretinism.

(Motors, honking, traffic sounds)

GALPIN: And it's here, in the north of the country, that the worst effects of the iodine shortage can be found. This is the main market in the northern town of Chitral, high up in the Hindu Kush mountains that straddle the border between Pakistan and Afghanistan. In front of me, many severely mentally and physically disabled people are begging on street corners. There's no support network for them here provided by the state, and a handicapped person is a huge burden to a family in this impoverished area. Steve Omemato of UNICEF says their fate is sealed.

OMEMATO: I assume that some of these children that we've seen abandoned, the ones you saw in Chitral, have in fact been thrown out of the family, and they survive as best they can and some of them don't survive very well or very long.

(A man sings)

GALPIN: In the picturesque villages further north of the Chitral valley, yet more evidence of the devastating impacts of the lack of iodine. This is Lal, who's now in his 80s. He sits singing old folk songs with his family.

(Lal sings)

GALPIN: He, like many of the people of this remote and beautiful region, suffers from goiter. The thyroid gland in his neck has swollen to the size of a football, a direct result of iodine deficiency. He's also deaf and severely mentally disabled, and it's a problem that spread to the younger generation. His daughter can neither hear nor speak. Dr. Sada Ulmuk, who's from Chitral, has dedicated his life to trying to combat iodine deficiency. He more than anyone knows that this is not just a problem affecting the old generation in the area.

ULMUK: It's affecting the health of the growing children; a large percent of schoolchildren still have goiter, up to 20%.. And many mothers lose their babies before time. And a large number of infants die prematurely. In the other periods of growing, it's an important cause of infertility, miscarriages, and poor health of the adult.

GALPIN: While iodine deficiency is a natural phenomenon in mountain regions across the world, the tragedy in Pakistan is that the problem has spread to other, low-lying, southern parts of the country, in part it seems because of damage to the environment. Dr. Attiv Sadi of the World Conservation Union in Pakistan explains how deforestation, frequent flooding of the largest river, the Indus, and iodine deficiency, are all linked.

SADI: Because of increased deforestation in the watershed area of Indus, the water overflows to lands where it has never flown, and it removes iodine from the soil.

(Music with voice-over)

GALPIN: And yet, despite the enormity of the problem, there is a cheap, simple, and extremely effective solution for iodine deficiency.

(Music continues; a man sings; a woman's voice-over)

GALPIN: This is one of many television advertisements promoting the use of table salt with iodine added to it. The government, the United Nations, and several aid agencies have all been working hard in recent years to try and convince the population to buy iodized salt, as well as persuading the manufacturers to make it.

(Ambient voices)

GALPIN: And it is gradually becoming available across the country, even in remote areas such as Chitral. This is one of several shops in the main market in Chitral town selling iodized salt. By using this regularly, a family can ensure sufficient iodine intake to compensate for what they should get naturally from their food. While the consumption across Pakistan has increased dramatically since the campaign began in the mid-1990s, there are many problems.

(A horn beeps amidst the market)

GALPIN: Not least is a suspicion amongst the population, particularly in the north, about the side effects of eating iodized salt.

MAN: [Speaks in Pakistani]

GALPIN: This man said he'd never buy it because he believed it made you weak and infertile. As the government and international aid agencies have tried to promote the sale of iodized salt, a rumor has spread rapidly amongst the population that it's in fact a form of family planning being imposed secretly by Western organizations. Imrim Said of the aid agency Social Marketing Pakistan says this is having a disastrous effect on the campaign to increase consumption.

SAID: The rumor that iodized salt is linked with family planning and causes infertility and impotence is primarily what's holding the project back. And, you know, the targets we have of achieving 100% iodization by the year 2000, end 2000, we won't be able to reach that unless we can properly address this rumor.

GALPIN: At present, it's estimated only around a third of all families in Pakistan are using iodized salt. And the government's already been forced to revise its target of 100% iodization to the year 2003. While Steve Omemato of UNICEF says efforts are being made to combat the rumor, he admits that the whole approach to the promotion campaign needs to be changed.

OMEMATO: I think some of the early communications campaigns focused much too much on the conventional, modern media. Newspapers, radio, and television. The people who you saw in Chitral, and the people I've seen in other areas of Pakistan who are most in need, are very poor families. They do not watch television. They may not even have a radio. And they are not literate and therefore they cannot benefit from the media. So, in our current phase, we are moving far beyond the conventional media and trying to reach, by word of mouth, into remote communities and into the poorest households of all communities, through health workers, through schoolteachers, through community leaders, and even through religious leaders.

GALPIN: But there are other obstacles, too.

(Clanking sounds, engines)

GALPIN: This is one of the many salt processors in Pakistan. In fact, there are hundreds of small companies scattered throughout the country. The task of encouraging them all to install the necessary equipment so they can produce iodized salt is therefore much more difficult.

MAN: [Speaks in Pakistani]

GALPIN: Salt processors such as this man in Rawalpindi confirm this, and say consumer demand for iodized salt is being held back, both by the rumor about the link with family planning, and by the fact that it's more expensive than ordinary salt. Faced with all these difficulties, Dr. Mushtak Khan, a government nutrition specialist, says Pakistan needs more financial assistance from abroad if iodine deficiency is to be tackled successfully.

KHAN: Unless we have resources from the international community, whether it's multinational, international, or bilateral, it will be a very difficult task to meet these targets from the domestic resources.

GALPIN: But it's not just a question of money. Other specialists argue that the government itself could do much more. For example, by passing legislation at the national level, to force all salt processors to produce iodized salt.

(Children; a man calling out)

GALPIN: Whichever's the best way forward, in the final analysis this is a race against time for children such as these at school in Chitral. At present the mental and physical development of much of the young generation in Pakistan is being held back due to the lack of a simple nutrient in the diet.

(Man continues calling, speaking)

CURWOOD: That report on iodine deficiency in Pakistan was produced by Richard Galpin.